Archive | December, 2018

Issue LXVI: The Fall in Life Expectancy is a Fall in Expectations

19 Dec

American life expectancy has fallen for the third year in a row.  The Centers for Disease Control and Prevention has reported that life expectancy fell in 2015, 2016, and 2017.  That is two years of President Obama’s time in office and one year of President Trump’s time in office.  This is a bipartisan crisis.

This is an indictment of our political, media, and health care systems.  People are dying who shouldn’t be dying.

This simple fact should be repeated in the news day in and day out.  Local reporting and national media outlets should be targeting and following up on the hot spots of this crisis.

Absent a civil war or the AIDS pandemic in Africa, this has not been seen in international health.  The last time life expectancy fell in the United States it was 1993 during the height of the HIV epidemic.  That decline lasted a single year.  Three years in a row of declining American life expectancy has not occurred since World War I.

Only honest, independent criticism will fix this problem after a cold hard look at the facts.  We cannot treat unless we diagnose.

Since 2000, suicide has risen 18% in the United States while it has fallen 29% across the rest of the world according to The Economist.  The suicide rate (13.4 per 100,000 people) was below the world average and now it is above the world average.  It is now inching towards the high but declining rate of Japan, a nation once famous for seppuku suicide rituals among samurai.

Much of this is due to much laxer gun laws in the United States than other nations since firearms are a common method of reducing suicide.  Australia famously saw a large drop in murders when it passed gun control laws in the 1990s, but the effect on suicides was even larger.  Suicide rates vary between states but are high in states with high gun ownership rates (Alaska) and lower in states with fewer guns (New Jersey).

But the gun issue would be misleading in the American context as the percentage of households owning guns has been declining or at least stagnant since the 1990s.  The rise in gun sales is going to existing gun owners (more guns in fewer households) not to families who never owned guns in general.

What instead is occurring are “deaths of despair” as Nobel Prizing-winning Princeton economist Angus Deaton put it.  The rising gap between rich, poor, and middle class is also killing people on a grand scale according to the Dr. Michael Marmot at University College London.  Inequality is bad for your health.

The striking increase in death rates in the United States is driven by whites without college degrees.  One would first think that this is related to the opiate crisis of the last few years, and one would be partially right.  However, drug, alcohol, and suicide deaths have been rising since approximately 1990.  It is thought to be linked to the lack of steady, well-paying jobs which began to disappear for the high school-educated in the 1990s.  The increase in the Hispanic population (which paradoxically has lower mortality rates than whites) may have masked these life expectancy declines because they live three years longer than non-Hispanic whites.

The closest international analogy to the United States is the former Communist bloc nations of Eastern Europe and Russia in the 1990s.  The economic collapse of Russia after the fall of the Soviet Union led to millions losing their guaranteed jobs for life.  The government privatized state-owned companies and cut back massively on the public health system.  Joblessness skyrocketed and suicides and alcohol abuse did too.  Male life expectancy fell almost a decade to 57 years.  People stopped having children too.

Obviously, the health and economic situation is not nearly as dire in the United States today but there are parallels such as the dramatic drop in young people having children since the recession.  Companies who provided jobs for life such as General Motors and IBM with generous pensions benefits did not go out of business like in Russia but began to end those guarantees for new employees while downsizing the overall headcount.  Public spending cuts supervised by the International Monetary Fund increased tuberculosis deaths in Eastern Europe.  American budget austerity has likewise contributed to the dramatic increase in STDs including gonorrhea and syphilis after reaching record lows.

At the end of the day, the blame for the three-year fall in American life expectancy despite the increase in the percentage of people with health insurance points to the importance of the social determinants of health.  A health care system focused completely health insurance payment models than actual people’s health is a product of a political system focused completely on campaign profits than actual voter’s social, job, and health needs.  America’s politics is actually making us sick.


The Economist –Suicide is declining almost everywhere

National Public Radio – “Deaths of Despair



Issue LXV: Myths and Lies of the Quality Industrial Complex

16 Dec

The Cost Conundrum Re-visited

A pediatric pulmonologist at a prominent Midwestern children’s hospital told me a story about a conversation he had in Iowa City. When he was in training, a faculty member bragged about how he had the best asthma outcomes in the nation. He felt like the medical school, support staff, and community were doing better than anyone else. A visiting pediatrician from Georgia laughed, “Guys!  You are in I-O-W-A. I am in Atlanta. Of course, you have the best results. It’s completely different here.”

Anyone who has been to Iowa and Atlanta would easily notice the difference. I have not been to either, but I have practiced medicine in three different states in many different clinics and hospitals. It is very obvious that geography, poverty, economics, and insurance plans matter more than what the physician or hospital does for any given outcome.

This basic truism is not remarkable except when you realize that the entire health care debate of the Obama era consisted of ignoring these basic facts. If you follow the elite popularizers of health policy amongst the neoliberal press, you may believe that the United States faces an epidemic of unnecessary care by greedy physicians. This creates some regions with high spending and poor health, some regions with low spending and great health, or a mixed picture. Why would that be true?

Dr. Atul Gawande’s famous 2009 article about excessive Medicare spending in McAllen, Texas in the New Yorker revolutionized the conversation. He argued that the very high Medicare spending in McAllen must be due to greedy hospitals and physicians bilking insurance for more services (hospital days, office visits, scans, procedures, and prescriptions) than anywhere else in the United States. The volume of patient services must not be justifiable.

President Obama recommended his Cabinet to read it. According to Gawande, 30% of health care spending in the United States was “of no obvious clinical benefit” (aka waste). Peter Orszag, Obama’s budget director, evangelized these results to Congress and the media. To make the Affordable Care Act affordable, federal health policy should begin to equalize spending between high and low spending regions while maintaining quality.

Based on a once obscure dataset called the Dartmouth Atlas, federal health policy shifted towards justifying and measuring “quality” to prove effective care throughout the nation. Accountable Care Organizations, Big Data, and integrated care delivered via electronic medical records became the mechanisms to do this. Medicare introduced free market correctives such as non-payment for medical errors and “excessive” readmissions and rewards for patient satisfaction and electronic medical records.

The problem is the diagnosis is wrong; therefore, the carrot and stick solutions will fail too. American health spending is high not primarily due to waste or widely different practice patterns that can be easily quantified and equalized. It is a lie on the level of Bush’s missing weapons of mass destruction but with more annual American (not Iraqi) casualties and financial havoc on the lives of physicians and patients. Just as members of the congressional committee on intelligence did not know the difference between Sunni and Shi’ite groups in the Middle East, the federal bureaucracy cannot spot the difference between low spending Utah and Dubuque, Iowa and high spending Miami and Los Angeles.

These lies need to be exposed and fought the way CNN’s Jake Tapper’s misleading comments about Medicare for All were. Here is a short rebuttal of the Quality Industrial Complex’s insistence that American spending is high because of unnecessary health care usage.

Costs = Prices x Volume

Revenue in any business or organization is equal to price multiplied by volume of units sold or used. Businesses can have large revenues selling many items cheaply (Wal-Mart) or few units expensively (Luis Vuitton). Which company is the U.S. health system?

Well, neither. It’s more like a Marc’s or Ohio Discount Drug Mart with Luis Vuitton prices. The late Princeton economist Uwe Reinhardt analyzed prices and volumes throughout developed nations and concluded in 2003, “It’s the Prices Stupid.” The United States had astoundingly high prices but average volumes compared to other OECD nations. A complex analysis performed in the March 13, 2018 issue of the Journal of the American Medical Association concluded again that the United States had very high prices and quadruple the administration costs but normal to below average volumes in most services: hospital visits, office visits, and drug prescriptions.

The United States stands out with its fragmented health financing, health spending, complicated tax breaks, and multiple public and private insurers. But one factor that stands out above all is the lack of standardized prices for hospital stays, office visits, surgeries, and prescription drugs. Not using monopsony power (purchasing monopoly via negotiations) to counteract physician, hospital, and drug monopolies, higher prices prevail.

Indeed, since the Affordable Care Act was signed and Trump’s inauguration, the biggest scandals have all been price related. There have been outrageous increases in antibiotic prices, murderous raises in EpiPen prices, large deductible and premium hikes, and ludicrous shortages of generic medications, and even IV fluids. The government has been powerless to do anything as there are no price controls in the Affordable Care Act.

High Volumes, High Poverty

What about high spending regions that have worse outcomes? Is that all a myth? No, not exactly. But it only puzzles someone who ignores another American exceptionalism: poverty. No other developed nation has such high levels of income inequality, concentrated poverty, residential segregation, and a meager welfare state, particularly for children and mothers.

Why would Miami, Los Angeles, McAllen, or New York have high health spending while Iowa and Utah and Grand Teton, Colorado have “low” spending? It’s obvious: the former have many neighborhoods of concentrated poverty, low education, and high income inequality while the latter do not. The late Dr. Richard Cooper, an oncologist and Wisconsinite, emphasized this difference in his posthumous book Poverty and the Myths of Health Care Reform. And since prices are high throughout the U.S., only volume can explain the differences in health spending.

Surprised to see his hometown of Milwaukee spending 35% more than the rest of Wisconsin, he performed ZIP code level analysis of the region and found that high utilization was occurring in a specific high poverty corridor. Indeed, Milwaukee is the most segregated city in the United States. Excluding the high poverty corridor showed usage in the Milwaukee region to be no different than the rest of Wisconsin, a state with less inequality and more education than the rest of the United States. He performed the same analysis and found the same results in New York City and Los Angeles. In one memorable chapter titled “Riding the A Train”, he demonstrated how life expectancies increased as one went from Harlem to lower Manhattan then went down again after entering Brooklyn.

This fact should not be surprising at all, as it is known to occur in all nations. Poor people are less healthy than middle income people who are less healthy than high income people. Michael Marmot demonstrated this with his famous Whitehall Study on the social determinants of health of civil service workers in Britain. Many mental and physical health problems have been shown to be affected by one’s job rank, education, and even type of contract (temporary or long term) internationally.

Ironically, the one American population that consistently gets medical and social welfare spending is the elderly. And the American health system, shockingly, has the highest life expectancy for those who make it to 65 in the OECD. If we had a similar investment in child and parental welfare, we might see the same results in infant and maternal mortality.

This insight makes the strategy of ignoring prices and poverty and focusing on patient volumes even more dangerous.

Perils of a Volume First Strategy

A volume first strategy focuses on the appropriate utilization of care in hospitals, clinics, and operating rooms. This would involve “integration,” “accountable care,” or “clinical coordination.” In actual practice, it just means mergers.

Solo physicians who made partnerships and then large physician groups are now selling these groups to hospitals. Community hospitals have become part of larger hospital chains.  The point of the mergers is to increase negotiating power with insurance companies, to force them to pay the highest rates. Physicians’ practices (now under hospital ownership) become much more expensive, with the same visit being billed with more expensive codes and with “facility fees”. While the doctors and procedure haven’t moved an inch, the charges have increased dramatically.

Typically, the largest of chain hospitals in any given region introduce their own insurance products, which restrict a customer’s ability to use any facility or physician that they do not control. Networks of “preferred providers” create confusing and costly “in network” and “out of network” charges for patients. Patient satisfaction scores, unwieldy EMRs, and clinical documentation initiatives have created a new tier of administrative employees to manage and monitor physicians’ behaviors.

The quality industrial complex has attacked physician’s autonomy and done nothing to reduce the unquestionably unusual part of the American health system by international standards– high prices and high overhead costs. The “P” of Prices is only getting worse. Instead of a few simple macro-regulations of price setting and global budgeting, hundreds of micro-regulations have been unleashed to control physician behavior and patient utilization. The following is a dramatic example.

Many people know about how patient satisfaction scores may have fueled the opiate crisis (leading to the deaths of thousands annually), but few may know about the Hospital Readmissions Reduction Program (HRRP). Heart failure patients are infamous for returning to the hospital soon after being treated for heart failure exacerbations. Medicare thought that reducing readmissions would save the health care system money. This program to reduce heart failure readmissions (volume control) at 30 days and 1 year was successful. The problem? Patients were not being readmitted because they were dying at home. This volume control program potentially killed 5,000 to 10,000 people as volumes decreased and mortality rates increased over 8 years.

The myth that a third of health care spending is wasted due to unnecessary usage as opposed to high prices, high administration costs and high poverty rates in the United States is probably just that, a political myth. The Darmouth-Orszag-Gawande gang have committed malpractice by perpetuating this fable across the political media. It is a fable popular in a Washington eager to justify spending cuts, attacks on clinical autonomy, and ignoring the real work of bringing hospitals, insurers, and pharmaceutical companies to heel.

November 7, 2018 – Texas Elections

16 Dec

Well Texas…. I know it hurts to see Lyin’ Ted win again, indicted Ken Paxton squeak by, and Dan “Bathroom Bill” Patrick close the door on us.

You know us, the open-minded and open-hearted, diverse and multilingual Texas. We who may not be wearing the cowboy garb of legendary lore, but we are legendary in our own way too. Legends in the frontier of human existence, science, art, and writing. Ideally as cosmopolitan as New Yorkers without the attitude and as relaxed as Californians without the brittleness. We who still go big like the old timers do but in the new economy and old. Cognizant of who we were and pushing toward who we should be.

Our time will come.  For in their grasp of victory drops the seeds of their destruction.  And we grow from this seed and rise to bring forth that future where we live large, dream large, and do large in all things for the world but not against it.

We are not a small, fearful people.  And for that reason our Texas – from Galveston to El Paso – will win.

Good night Texas. We’ll make it there one day.